Hyponatremia is an electrolyte disorder that is defined by a serum sodium concentration of less than 136 mmol/L. Hyponatremia occurs at a high incidence. It is commonly associated with mild to moderate mental impairment. Hypoosmolar hyponatremia occurs in the setting of plasma volume deficiency ("hypovolemia", e. g. after gastrointestinal fluid loss), liver cirrhosis and cardiac failure ("hypervolemic" hyponatremia) and syndrome of inappropriate antidiuretic hormone secretion ("euvolemic" hyponatremia). Excessive antidiuretic hormone and continued fluid intake are the pathogenetic causes of these hyponatremias. Whereas hypovolemic hyponatremia is best corrected by isotonic saline, conventional proposals for euvolemic and hypervolemic hyponatremia consist of the following: fluid restriction, lithium carbonate, demeclocycline, urea and loop diuretic. None of these nonspecific treatments is entirely satisfactory. Recently a new class of pharmacological agents -orally available vasopressin antagonists, collectively called vaptans- have been described. A number of clinical trials using vaptans have been performed already. They showed vaptans to be effective, specific and safe in the treatment of euvolemic and hypervolemic hyponatremia.
Background To evaluate the status of overweight and obesity in a Chinese rural adult population and describe relationships between body mass index (BMI) and blood pressure according to JNC-7. Methods The study was conducted in 2004-2006, used a multistage cluster sampling method to select a representative sample. A total of 45,925 adults, age 35 years or older, were examined. Height, weight and blood pressure were obtained by trained doctors. Overweight and obesity were defined according to the World Health Organization classification and Chinese definition. Results The prevalence of overweight and obesity were 16.3% and 1.3% in males, and 24.4% and 2.7% in females (p for gender differences <0.05) according to the World Health Organization classification; The prevalence of overweight and obesity were 29.5% and 5.3% according to the Chinese definition.The prevalence of elevated blood pressure (prehypertension and hypertension) and mean levels of systolic and diastolic blood pressure increased as BMI increased. Multivariate logistic regression revealed that overweight and obesity were risk factors for prehypertension and hypertension whether in males or females. Conclusions Overweight and obesity has become very prevalent in the Chinese rural adult population. It is a great health problem. Our study quantifies the strong associations of BMI and elevated blood pressure. It is time to pay more attention to overweight and obese in the county of China.
Objective In patients with acute myocardial infarction (AMI), angiographic slow/no-flow during percutaneous coronary intervention (PCI) may lead to unfavorable outcomes. The aim of our study was to investigate the predictors and long-term prognosis of AMI patients with angiographic slow/no-flow. Methods We evaluated 228 consecutive AMI patients with either normal flow (Thrombolysis in Myocardial Infarction [TIMI] flow grade 3)(n=192) or slow/no-flow (≤TIMI-2)(n=36) based on cineangiograms performed during PCI. Results Multivariable analysis demonstrated that a long lesion (≥10 mm)(odds ratio [OR], 3.514; 95% confidence interval [CI], 1.505-8.206; p=0.004) and acute hyperglycemia (≥180 mg/dl)(OR, 3.011; 95% CI, 1.211-7.485; p=0.018) were significant and independent predictors of angiographic slow/no-flow. Further, we found that there was a high correlation (89%) for predicting angiographic slow/no-flow when the optimal cut-off values of lesion length (10.45 mm) and blood glucose levels on admission (187.5 mg/dl) were combined as identified by analysis of the receiver operating characteristic curves. One-year mortality and incidence of major adverse cardiac and cerebrovascular events (MACCE) were significantly higher in the slow/no-flow group than that in the normal flow group. Angiographic slow/no-flow was independently predictive of MACCE (hazard ratio [HR], 3.642; 95% CI, 1.208-10.980; p=0.022) and cardiac death (HR, 5.287; 95% CI, 1.155-24.204; p=0.032). Conclusions Lesion length and blood glucose level on admission can be used to stratify AMI patients into a lower or higher risk for angiographic slow/no-flow before optimal coronary intervention. In addition, angiographic slow/no-flow predicts an adverse outcome in AMI patients.
Objective We sought to determine the effect of impaired renal function (IRF) and diabetes on the long-term outcome in patients undergoing primary angioplasty for acute coronary syndrome (ACS). Background Diabetes and IRF occur frequently in patients presenting with ACS. However, the prognostic importance of IRF in comparison with diabetes after primary angioplasty has not been specifically studied. Methods A total of 742 patients with ACS treated by primary angioplasty were evaluated. Study endpoints were major adverse cardiac events (MACE), a composite of all-cause mortality, ACS, and target vessel revascularization (TVR). Results During an average follow-up period of 6.8 years, we documented 13 cardiovascular deaths, 27 non-cardiovascular deaths, 12 incidents of ACS, and 165 incidences of TVR. Six-year rates of MACE were significantly higher in diabetics with IRF (47.6%), nondiabetics with IRF (36.4%), and diabetics without IRF (36.0%) than in nondiabetics without IRF (28.4%, Log-rank test: p=0.0057). Nondiabetics with IRF, diabetics without IRF, and diabetics with IRF had a relative hazard ratio for MACE of 1.63 (95% confidence interval (CI) 1.04 to 2.54, p=0.033), 1.47 (95% CI, 1.03 to 2.11; p=0.036), and 1.97 (95% CI, 1.12 to 3.48; p=0.019), respectively, compared with nondiabetics without IRF. Conclusions IRF has an important association with MACE after primary angioplasty in patients with ACS and may be nearly as predictive of long-term outcome as is diabetes.
Objective To elucidate the clinical and radiological features of Pneumocystis pneumonia (PCP) in patients with rheumatoid arthritis (RA), compared with methotrexate (MTX) pneumonitis in RA and Pneumocystis pneumonia in acquired immunodeficiency syndrome (AIDS). Subjects and Methods Retrospective analysis of 14 PCP cases in RA (RA-PCP), 10 MTX pneumonitis cases in RA (MTX-P) and 11 PCP cases in AIDS (AIDS-PCP) from 9 centers in the Kanto area in the last 6 years. Results Compared with AIDS-PCP, both RA-PCP and MTX-P developed more rapidly, showing higher serum CRP and lower plasma β-D-glucan levels, and more severe oxygenation impairment. In most of the RA-PCP cases, a high dose of corticosteroid was administered as adjunctive therapy, resulting in a favorable outcome. The mortality was 14% in RA-PCP, 0% in AIDS-PCP and 0% in MTX-P cases. In RA-PCP patients the CD4 cell count showed only mild suppression, not reaching the predisposing level for PCP in HIV infection, suggesting that there are risk factors for RA-PCP other than immunosuppression. Radiologic analysis revealed some characteristic patterns of each disease. In MTX-P, diffuse homogeneous ground glass opacity (GGO) with sharp demarcation by interlobular septa (type A GGO) was found in 70%, while in AIDS-PCP diffuse, homogeneous or nonhomogeneous GGO without interlobular septal boundaries (type B GGO) was predominant (91%). In RA-PCP, type A GGO was found in 6 cases and type B GGO in 5 cases, showing the complex nature of this disease. Conclusion RA-PCP differed considerably from AIDS-PCP clinically and radiologically. Clinically it occurred without severe immunosuppression, and showed characteristic aspects, with more intense inflammation and less parasite burden. Radiologically it mimicked MTX-P in some cases sharing the conspicuous CT features of MTX-P, rendering the distinction of these two disorders difficult.
Objective The molecular basis for the antithrombin (AT) deficiency and dilated cardiomyopathy (DCM) combined in a Japanese patient was investigated. Methods We analyzed candidate genes -SERPINC1 for AT deficiency, and TNNT2 and LMNA for DCM. In addition, we examined the characteristics of recombinant mutant AT and evaluated the LMNA mutation associated with DCM by molecular modeling. Results Genome sequencing of SERPINC1 revealed a C-to-A transversion in exon 6 that resulted in a p.Pro439Thr mutation of AT, which was previously reported as a pleiotropic effect type II AT deficiency (AT Budapest5). However, expression experiments with recombinant 439Thr-AT showed normal heparin affinity, slightly reduced secretion, and low specific activity, which suggested that this mutation exhibits an intermediate feature of type I and type II AT deficiencies. In a survey of gene abnormalities causing DCM, we found no causative gene defect in TNNT2; however, we identified a G-to-C transversion in LMNA that resulted in a novel p.Asp357His mutation in lamin A/C. This acidic-to-basic residue substitution might have impaired the head-to-tail association of two lamin dimers leading to DCM. Further, we identified both SERPINC1 and LMNA mutations in the patient's daughter and son, both of whom had AT deficiency. These data suggested that a p.Pro439Thr mutation in SERPINC1 and a p.Asp357His mutation in LMNA might have cosegregated in this family, associated with AT deficiency and DCM, respectively. Conclusions We identified missense mutations in SERPINC1 and LMNA genes to be associated with AT deficiency and DCM, respectively, which might have cosegregated in the family of the patient.
Clinical and laboratory diagnosis of severe leptospirosis (Weil's disease) may be difficult when other pathological processes that may cause similar clinical syndromes or affect immune response to infections coexist. In addition, the optimal management of the disease remains to be defined. We report on a case of Weil's disease, in which concurrent chronic hepatitis B virus infection and alcohol abuse caused diagnostic and therapeutic difficulties.
A 58-year-old woman with chronic hepatitis C was admitted to our hospital to receive interferon (IFN) therapy. Twenty years earlier she had received blood transfusion because of obstetric hemorrhage. Blood test showed mild hypothyroidism and a relatively elevated eosinophil count. Therapy with pegylated IFNα-2a was started, and two days later she complained of nausea and severe malaise. Blood test showed hyponatremia, and plasma prolactin, growth hormone and cortisol levels were all decreased. A simultaneous administration test of lutenizing hormone releasing-, corticotrophin releasing-, growth hormone releasing- and thyrotropin releasing-hormones revealed that only adrenocorticotropic hormone was responsive. Magnetic resonance imaging showed atrophy of anterior lobe of pituitary gland. We diagnosed that IFN therapy disclosed latent Sheehan's syndrome due to previous obstetric hemorrhage. Following supplementation of thyroid and adrenal cortical hormones, we were able to complete IFN therapy. Thus, before IFN therapy for woman patients it is important to suspect latent Sheehan's syndrome when the patient had a history of obstetric hemorrhage.
We report a case of autoimmune pancreatitis (AIP) with cholangiography and histopathology showing features characteristic of primary sclerosing cholangitis (PSC) and colitis. A 55-year-old previously-healthy man was diagnosed with anti-nuclear antibody (ANA)-positive AIP according to the finding of serum biochemistry, abdominal US (ultrasonography), CT (computed tomography) and ERCP (endoscopic retrograde cholangiopancreatography). However, bead-like strictures of intrahepatic bile ducts were also found and liver tissue showed onion skin-like periductal fibrosis but no anti-IgG4-positive cells. In addition, colon fiberscopy showed a pancolitis similar to ulcerative colitis indicating that, in this case, there may be an association with PSC. Here, we report a rare case of IgG4-negative AIP with sclerosing cholangitis and colitis with many clinical features that support an association with PSC.
The patient was a 75-year-old man. He had been diagnosed with gastric hyperplastic polyp 4 years previously. The color of the apex of this polyp was whitish. Magnifying endoscopy findings revealed disappearance of the mucosal microstructure with irregular branched capillaries at the top of the polyp. Endoscopic mucosal resection (EMR) was performed. Histological examination revealed that a part of the polyp surface was replaced with papillary adenocarcinoma. Diagnosis of papillary adenocarcinoma in a hyperplastic polyp with mucosal invasion was made. Magnifying endoscopy was useful for the detection of gastric cancer occurring in the hyperplastic polyp in the present case.
We report a rare case of spontaneous rupture of idiopathic thymic abscess into the pleural cavity. A 64-year-old woman was admitted to hospital with pleuritic retrosternal chest pain. Chest roentgenograms disclosed a small amount of bilateral pleural effusion, the examination of which exposed a sterile serous exudate with a markedly increased CA-125 level. Chest computed tomography revealed a large anterior mediastinal cystic mass with bilateral pleural effusions. Following complete resection of the mass, the histological examination revealed cavitary lesion with necrotic thymic tissue and inflammatory infiltrate surrounded by fibrous wall. The immunohistochemical staining for CA-125 displayed strong positivity at the Hassall's corpuscles. Cyst fluid also revealed a highly elevated CA-125 level. Her serum CA-125 concentration two months after surgery had fallen to 28 IU/L. She is now doing well without recurrence of the cyst five months after surgery.
This report describes a 37-year-old man with tumor-induced osteomalacia (TIO). The patient had hypophosphatemia and elevated fibroblast growth factor 23 (FGF23) in the peripheral blood. Magnetic resonance imaging detected an abnormal mass in the left greater trochanter. Venous sampling revealed a significantly higher level of FGF23 in the left common iliac vein (proximal to the tumor), verifying that the tumor is responsible for TIO. The serum level of FGF23 decreased and symptoms improved after removal of the tumor. The combined diagnostic procedures of MRI and venous sampling for FGF23 effectively detected the tumor responsible for TIO.
We report a case of hypereosinophilia associated with increased serum levels of carcinoembryonic antigen (CEA). The patient developed fever, diarrhea, erythroderma and eosinophilia. Disorders known to be associated with eosinophilia were not detected. The typical malignant diseases related to a rise in CEA levels were not identified. The CEA value reached a maximum of 81.4 ng/ml a few weeks late for the peak of the eosinophilic count. Corticosteroid therapy was effective in improving clinical symptoms and the CEA values decreased in association with the improvement of those manifestations, suggesting a pathophysiological link between the disease activity of hypereosinophilia and the changes in CEA level.
A previously healthy middle-aged woman noted a rapid onset of flank pain with gross hematuria. Enhanced CT scan showed thrombosis of the inferior vena cava and right renal vein. Laboratory findings revealed nephrotic proteinuria, Sjogren's syndrome (SjS), and Graves' disease (GD). A right nephrectomy was performed because of progressive and refractory renal necrosis. Renal specimens showed venous infarction with diffuse hemorrhagic and severe congestive renal necrosis, and membranous nephropathy (MN). The present case was diagnosed as acute renal necrosis due to catastrophic thrombosis in a patient with SjS, GD, and MN. It was thought that sudden development of thrombosis may have been caused by the status of the autoimmune disorders, and the associated MN.
Early diagnosis of intravascular large B-cell lymphoma (IVLBCL) is difficult, but is critical for longer survival for the patients. We report a case of IVLBCL that was diagnosed with the help of FDG-PET. A 76-year-old woman was referred to us for the evaluation of her elevated serum LDH. She presented with general malaise and high fever. There were no skin lesions or neurological involvement. FDG-PET imaging showed increased uptake of FDG in the vertebra, bilateral femurs, sternum, and iliac bones. A diagnosis of IVLBCL was made by bone marrow biopsy. She was successfully treated with rituximab and modified CHOP therapy.